Temporary placement of a fully covered self-expandable metal stent in the pancreatic duct for management of symptomatic refractory chronic pancreatitis: preliminary data (with videos)

Endoscopic Retrograde Cholangiopancreatography for Management of Chronic Pancreatitis

Management of symptomatic chronic pancreatitis (CP) has shifted its approach from surgical procedures to minimally invasive endoscopic procedures. Increased experience and advanced technology have led to the use of endoscopic retrograde cholangiopancreatography (ERCP) as a therapeutic tool to provide pain relief and treat CP complications including pancreatic stones, strictures, and distal biliary strictures, pseudocysts, and pancreatic duct fistulas. In this article the authors will discuss the use of ERCP for the management of CP, its complications, recent advancements, and techniques from the most up to date literature available.

Advances in the Management of Pain in Chronic Pancreatitis

PURPOSE OF REVIEW

The data on recent advances in managing chronic pancreatitis (CP) pain is limited. This review highlights the role of endotherapy and the advances in the overall management of pain in CP.

RECENT FINDINGS

Of late, pancreatic biodegradable stents have been used in endotherapy with appreciable success. These include slow, medium, and fast degrading stents, which optimize the overall management of CP and could prevent the need for multiple procedures. Endoscopic ultrasound-guided celiac plexus block is reserved in selected patients to treat debilitating pain. Total pancreatectomy with islet autotransplantation in small duct disease has shown promising results. The indications for treating pain in CP with endoscopy and surgery need to be better defined. The complexity of pain control due to the incomplete understanding of pathomorphology makes the management of CP challenging. The current treatment methods are still evolving. Therapy aims to reduce pain, optimize recovery, maintain quality of life, and meet postoperative needs. Initial management includes lifestyle modification, nutrition optimization, risk factor reduction with abstinence from alcohol, cessation of tobacco and smoking. Supportive medical management involves the judicial use of analgesics, neuromodulators, antioxidants, pancreatic enzyme replacement for insufficiency, and diabetes management. Patients with intractable pain are ideal for therapeutic intervention. Being less invasive with an acceptable complication rate makes endotherapy the preferred first-line treatment. If found to be cost-effective, biodegradable stents can reduce the overall cost. Unfortunately, if patients remain symptomatic, surgery is preferred in case of failure or recurrence. For optimal results, appropriate patient selection is vital to maximizing outcomes.

Self-expanding metallic stent for refractory pancreatic duct stricture in chronic pancreatitis: A prospective follow-up study

BACKGROUND AND AIMS

In chronic pancreatitis, fully covered self-expanding metal stents (FCSEMS) are used to treat refractory pancreatic duct strictures. However, the FCSEMS design, effectiveness, safety, optimal stent indwelling time and patient selection remain unclear. This study aimed at evaluating technical success, clinical success and adverse events with FCSEMS in patients with symptomatic pancreatic duct stricture.

METHODS

The prospective study was conducted between May 2017 and May 2021 at a tertiary care center for chronic pancreatitis with refractory pancreatic duct stricture using controlled radial expansion (CRE) endoscopic retrograde cholangiopancreatography (ERCP) with FCSEMS (Niti-S, Bumpy stent, Taewoong Medical, Gimpo-Si, South Korea).

RESULTS

During the study period, a total of 11 patients underwent ERCP with FCSEMS for refractory pancreatic duct stricture. The mean age (± standard deviation, [SD]) was 32.36 ± 10.98 years and nine patients (81%) were male. Technical and clinical success rates were 100% and 90.9%, respectively. All patients had a history of prior pancreatic endotherapy. The median (inter quartile range, [IQR]) stent indwell time was seven (6-10) months. The median visual analogue scale (VAS) pain score pre and post-FCSEMS was 8 (5-8) and 1 (0-2), respectively (p-value 0.003). Median (IQR) follow-up after stent removal was 48 (40-60) months. One patient (9%) developed de novo main pancreatic duct (MPD) stricture, which was asymptomatic. None of the patients had cholangitis, pancreatitis, perforation, proximal migration or stent fracture.

CONCLUSION

The FCSEMS treatment appears to be safe, feasible and possibly an effective option for patients who have not responded to endoscopic plastic stenting.

Pancreatic duct stents

Pancreatic duct stenting using endoscopy or surgery is widely used for the management of benign and malignant pancreatic diseases. Endoscopic pancreatic stents are mainly used to relieve pain caused by chronic pancreatitis and pancreas divisum, and to treat pancreatic duct disruption and stenotic pancreaticointestinal anastomosis after surgery. They are also used to prevent postendoscopic retrograde cholangiopancreatography pancreatitis and postoperative pancreatic fistula, treat pancreatic cancer, and locate radiolucent stones. Recent advances in endoscopic techniques, such as endoscopic ultrasonography and balloon enteroscopy, and newly designed stents have broadened the indications for pancreatic duct stenting. In this review we outlined the types, insertion procedures, efficacy, and complications of endoscopic pancreatic duct stent placement, and summarized the applications of pancreatic duct stents in surgery.

A prospective study of fully covered self-expandable metal stents for refractory benign pancreatic duct strictures

BACKGROUND/AIMS

Fully covered self-expanding metal stents (FCSEMSs) are a relatively novel option for treating painful main pancreatic duct refractory strictures in patients with chronic pancreatitis. Herein, we aimed to assess the efficacy, feasibility, and safety of FCSEMSs in this patient group.

METHODS

This prospective single-center study included patients who underwent endoscopic retrograde pancreatography with FCSEMS placement. The primary endpoints were the technical and clinical success rates. A reduction in visual analog scale pain score of >50% compared with that before stent placement was defined as clinical success. Secondary endpoints were resolution of pancreatic strictures on fluoroscopy during endoscopic retrograde pancreatography and the development of stent-related adverse events.

RESULTS

Thirty-six patients were included in the analysis. The technical success rate was 100% (n=36) and the clinical success rate was 86.1% (n=31). There was a significant increase in stricture diameter from 1.7 mm to 3.5 mm (p<0.001) after stent removal. The mean visual analog scale pain score showed statistically significant improvement. At 19 months of follow-up, 55.6% of the patients were asymptomatic. Stent migration (16.7%), intolerable abdominal pain (8.3%), development of de novo strictures (8.3%), and mild pancreatitis (2.8%) were the most common adverse events.

CONCLUSION

FCSEMS placement showed good technical and clinical success rates for achieving pain relief in patients with refractory main pancreatic duct strictures.

Covered self-expandable metal stents for pancreatic duct stricture: a systematic review and meta-analysis

Background and study aims  Placement of a covered (C)-self-expandable metal stent (SEMS) has been recently investigated as an alternative endoscopic treatment for main pancreatic duct stricture (MPDS) in chronic pancreatitis. Our aim was to carry out a systematic review and meta-analysis of studies quantifying efficacy and safety of C-SEMSs in the management of MPDS. Methods  A multiple database search was performed, including MEDLINE, Embase and Cochrane Library, from January 2000 to September 2020, to identify studies reporting the efficacy and safety of C-SEMSs in patients with MPDS. Stricture and pain resolution were investigated. Other outcomes included technical success, stent migration, stricture recurrence and need for repeated stent placement. Pancreatitis, severe abdominal pain requiring stent removal and de-novo stricture were recorded as complications. Results  Nineteen studies were identified, which included a total of 300 patients. C-SEMSs showed a pooled stricture resolution rate of 91 % [95 % confidence interval (CI), 85 %-96 %] and a pooled pain resolution rate of 92 % (95 % CI, 85 %-98 %). The pooled proportion for stricture recurrence was equal to 6 % (95 % CI, 1 %-14 %), while stent migration occurred in 33 of 300 patients, the pooled proportion being 7 % (95 % CI 1 %-15 %). The pooled mean stent duration was 133 days (95 % CI, 100-166 days). The most common complication was pancreatitis (3 %, 95 % CI 0 %-8 %), while de-novo stricture pooled proportion was 2 % (95 % CI, 0 %-5 %). Conclusions  C-SEMSs are effective and safe in the treatment of MPDS. However, there is a significant need for further high-quality, well-designed studies to produce evidence-based data on short and long-term efficacy, safety, costs of C-SEMSs, and also optimal stent duration.

Current advances in the management of chronic pancreatitis

Chronic pancreatitis is characterized by irreversible destruction of pancreatic parenchyma and its ductal system resulting from longstanding inflammation, leading to fibrosis and scarring due to genetic, environmental, and other risk factors. The diagnosis of chronic pancreatitis is made based on a combination of clinical features and characteristic findings on computed tomography or magnetic resonance imaging. Abdominal pain is the most common symptom of chronic pancreatitis. The main aim of treatment is to relieve symptoms, prevent disease progression, and manage complications related to chronic pancreatitis. Patients who do not respond to medical treatment or not a candidate for surgical treatment are usually managed with endoscopic therapies. Endoscopic therapies help with symptoms such as abdominal pain and jaundice by decompression of pancreatic and biliary ducts. This review summarizes the risk factors, pathophysiology, diagnostic evaluation, endoscopic treatment of chronic pancreatitis, and complications. We have also reviewed recent advances in endoscopic retrograde cholangiopancreatography and endoscopic ultrasound-guided therapies for pancreatic duct obstruction due to stones, strictures, pancreatic divisum, and biliary strictures.

Endoscopic management of local complications of chronic pancreatitis

Endoscopic treatment of local complications in patients with chronic pancreatitis has gained ground over the surgical alternative in the last few years. The lower aggressiveness of endoscopic treatment, as well as the possibility to use it repeatedly in high-risk patients, has favored this development. In addition, the incorporation of new, highly accurate endoscopic therapeutic options such as pancreatoscopy-guided lithotripsy and endoscopic ultrasound-guided treatments make endoscopic treatment the first choice in many cases, despite discordant data in the literature. This article reviews the endoscopic treatment of the most common local complications of chronic pancreatitis, such as pancreatolithiasis, pseudocysts, and pancreatic, biliary, and duodenal ductal stenosis.

International consensus guidelines on interventional endoscopy in chronic pancreatitis. Recommendations from the working group for the international consensus guidelines for chronic pancreatitis in collaboration with the International Association of Pancreatology, the American Pancreatic Association, the Japan Pancreas Society, and European Pancreatic Club

BACKGROUND/OBJECTIVES

This paper is part of the international consensus guidelines on chronic pancreatitis, presenting for interventional endoscopy.

METHODS

An international working group with experts on interventional endoscopy evaluated 26 statements generated from evidence on 9 clinically relevant questions. The Grading of Recommendations Assessment, Development, and Evaluation approach was used to evaluate the level of evidence. To determine the level of agreement, a nine-point Likert scale was used for voting on the statements.

RESULTS

Strong consensus was obtained for 15 statements relating to nine questions including the recommendation that endoscopic intervention should be offered to patients with persistent severe pain but not to those without pain. Endoscopic decompression of the pancreatic duct could be used for immediate pain relief, and then offered surgery if this fails or needs repeated endoscopy. Endoscopic drainage is preferred for portal-splenic vein thrombosis and pancreatic fistula. A plastic stent should be placed and replaced 2-3 months later after insertion. Endoscopic extraction is indicated for stone fragments remaining after ESWL. Interventional treatment should be performed for symptomatic/complicated pancreatic pseudocysts. Endoscopic treatment is recommended for bile duct obstruction and afterwards surgery if this fails or needs repeated endoscopy. Surgery may be offered if there is significant calcification and/or mass of the pancreatic head. Percutaneous endovascular treatment is preferred for hemosuccus pancreaticus. Surgical treatment is recommended for duodenal stenosis due to chronic pancreatitis.

CONCLUSIONS

This international expert consensus guideline provides evidenced-based statements concerning indications and key aspects for interventional endoscopy in the management of patients with chronic pancreatitis.

Chronic pancreatitis: an overview of diagnosis and management

INTRODUCTION

Chronic pancreatitis entails a heavy burden on the healthcare system because of its often protracted evolution, requiring complex diagnostic and therapeutic procedures.

AREAS COVERED

This review focuses on novel imaging and endoscopic diagnostic and therapeutic interventions that have changed the management of patients with chronic pancreatitis. We have conducted an extensive search of original papers and guidelines, in order to provide a comprehensive and up to date review of available evidence in these areas of interest.

EXPERT OPINION

The traditional challenges in managing chronic pancreatitis patients stemmed from the limitations of diagnostic modalities, which could not correctly identify patients in an early stage of the disease, as well as from the scarcity of therapeutic options available. Advances in imaging of CT-scan, MRI, and EUS have opened the way for early diagnosis and staging. This has allowed more aggressive and tailored therapeutic modalities, particularly in endoscopic therapy and minimally invasive surgical interventions. Although high-quality data from large RCTs is still scarce, evidence-based algorithms for diagnosis and therapy are now changing the way we address this chronic disease. In the near future, we can expect a tailored approach based on patient and disease-related predictive factors, relying on a vast armamentarium of endoscopic and surgical solutions.

Efficacy of fully covered self-expandable metal stents for the management of pancreatic duct strictures in chronic pancreatitis: A systematic review and meta-analysis

BACKGROUND AND AIM

Recently, there has been burgeoning interest in the utilization of fully covered self-expandable metal stents (FCSEMSs) for managing main pancreatic duct strictures (MPDS) in chronic pancreatitis (CP). The primary aim was to investigate stricture resolution and recurrence rates of FCSEMS placement in patients with symptomatic CP complicated with MPDS.

METHODS

MEDLINE, EMBASE, and ISI Web of Science and Cochrane Library (up to December 2019) were searched to identify eligible studies. A meta-analysis of stricture resolution and recurrence rates was carried out using R. The crude rate of adverse events related to stent therapy was also calculated.

RESULTS

Ten studies involving 163 patients were included. The weighted pooled rate of MPDS resolution was 93% (95% confidence interval [95%CI] 84-99%) with substantial heterogeneity (I²  = 63%). Duration of stent placement more than 3 months did not result in a significantly higher resolution rate than that of 3 months or less (93% vs 93%, P = 0.91). The weighted pooled rate of stricture recurrence was 5% (95%CI: 0-12%). The stricture recurrence rate for patients with duration of stent placement more than 3 months (3%; 95%CI: 0-10%) was lower than that in patients with 3 months or less of stent placement (7%; 95%CI: 0-23%), but not significantly (P = 0.45). The overall rate of adverse events related to stent therapy was 34.9%, and spontaneous stent migration occurred in 14.1% of patients.

CONCLUSIONS

The use of FCSEMSs appears to be effective and safe in the management of MPDS caused by symptomatic CP.

Endotherapy of postcholecystectomy biliary strictures with multiple plastic stents: long-term results in a large cohort of patients

BACKGROUND AND AIMS

Endoscopic therapy of benign biliary strictures with multiple plastic stent (MPS) placement has shown satisfactory results. However, the literature describes various benign biliary stricture etiologies. The aim of this study was to evaluate long-term MPS results in patients with postcholecystectomy biliary strictures (PCBSs).

METHODS

PCBS patients without complete bile duct transection were included. ERCP consisted of placing an increasing plastic stent number over time, exchanged at regular intervals (3-4 months), until complete morphologic stricture disappearance. After stent removal, patient follow-up comprised liver function tests and clinical assessment.

RESULTS

One hundred fifty-four patients (43.5% men; mean age, 53 years) were enrolled; in 43% of the cases, PCBSs were involved or were close to the main hepatic confluence. PCBS resolution rate was 96.7% (n = 149). A mean maximum number of 4.3 ± 1.6 stents were placed side-by-side; a mean of 4.2 ± 1.5 ERCPs per patient was needed to obtain PCBS resolution during a mean treatment period of 11.8 ± 6.4 months. Unscheduled stent exchange because of cholangitis, jaundice, or pain occurred in 7.4% of cases. Procedure-related mortality was absent. Follow-up data were available in 85.2% of cases. After a mean follow-up of 11.1 ± 4.9 years, stricture recurrence rate was 9.4% (n = 12). Subsequent to retreatment, 83.3% of patients (n = 10) were asymptomatic after a mean time of 9 years, whereas 2 patients underwent hepaticojejunostomy because of failed retreatment. Statistical analysis revealed no risk factors for PCBS recurrence after MPS.

CONCLUSIONS

Endoscopic therapy of PCBSs with MPSs is safe and effective at long-term follow-up. PCBSs involving or close to the main hepatic confluence were successfully treated with MPSs. PCBS recurrence rate is low and can be successful endoscopically retreated without precluding possible surgical treatment.

Fully covered self-expanding metal stents for refractory pancreatic duct strictures in symptomatic chronic pancreatitis, US experience

Background and study aims  Fully covered self-expanding metal stents (FCSEMS) have been used to treat refractory pancreatic duct strictures. We aimed to evaluate the feasibility, safety, and efficacy of FCSEMS in chronic pancreatitis with refractory pancreatic duct strictures. Patients and methods  This was a retrospective multicenter cases series of patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) with FCSEMS placement in the main pancreatic duct (MPD) at five tertiary care centers between February 2010 and June 2016. Primary endpoints were technical success, clinical success, and procedure-related morbidity. Secondary endpoints were pain relief at the end of follow-up and resolution of the pancreatic stricture on ERCP. Results  Thirty-three patients with previously drained stents, 76 % of whom were male, underwent ERCP with FCSEMS placement. Mean duration of follow-up was 14 months. All of the patients had prior therapy. The technical success rate for FCSEMS placement was 100 % (n = 33) and the clinical success rate was 93 % (was n = 31). Stents were removed after a median duration of 14.4 weeks. After stent removal, the diameter of the narrowest MPD stricture had increased significantly from 1 mm to 4.5 mm ( P  < 0.001). There was a statistically significant improvement on the Visual Analogue Scale (VAS) from a median of 8.5 to 2.5. At the end of the study, (n = 27) 87.1 % of patients reported significant pain reduction with reduced narcotic use. Conclusion  FCSEMS appeared to be a feasible, safe, and potentially effective Intervention in patients who had not responded to endoscopic therapy with plastic stents.

Fully covered self-expanding metal stents for benign refractory pancreatic duct strictures in chronic pancreatitis

Background: Pancreatic duct (PD) stricture is a common adverse event in chronic pancreatitis (CP). Primary treatment for refractory PD strictures is endotherapy (ET), including the insertion of multiple plastic stents. In addition, fully covered self-expandable metal stents (FC-SEMSs) have also been successfully used. More long-term studies are necessary to clarify the complication rate and efficiency, however. Methods: This retrospective study was comprised of 17 patients with symptomatic CP and refractory fibrotic main pancreatic duct (MPD) stricture treated with FC-SEMSs between 2010-2018 at the Helsinki University Hospital. Treated strictures were located in the pancreatic head. Technical success was defined as the accurate positioning of the stent and resolution of the MPD stricture. Clinical success was defined as pain relief at the end of the follow-up. Results: In 12 patients (71%), stricture resolution was accomplished. Clinical success was achieved in 12 patients (71%). The median duration of stenting was 169 days (range 15-804). Ten patients (58.8%) underwent a follow-up of two years or more. Early complications (≤7 days) occurred in two patients (12%): one pancreatitis and one cholestasis. Late complications (≥7 days) included severe abdominal pain (n = 2, 12%), pancreatitis (n = 3, 18%), cholestasis (n = 1, 6%) and stent migration (n = 7, 35%). Significant differences in stricture resolution and pain improvement were evident in patients with stent migration compared to patients without stent migration [1(14.3%) vs. 11(84.6%), p = .004 and 2(28.6%) vs. 11(84.6%), p = .022]. Conclusion: FC-SEMS placement is a safe and potentially effective treatment for this challenging group of patients. However, stent migration appears to affect the clinical and technical outcome.

Pilot Study of Dumbbell-Type Covered Self-Expandable Metal Stent Deployment for Benign Pancreatic Duct Stricture (with Videos)

BACKGROUND

Fully-covered, self-expandable metal stents (FCSEMS) have been deployed to treat symptomatic chronic pancreatitis (CP) complicated with main pancreatic duct (MPD) stricture. Although this strategy can be effective, it has the disadvantages of stent migration or stent-induced ductal change. Removal of an FCSEMS can also be challenging in the face of distal migration because of MPD stricture. Dumbbell-type FCSEMS have been developed to prevent stent-induced ductal changes and improve removability when treating benign biliary stricture. This stent might also confer clinical benefits upon patients with MPD stricture.

AIMS

The present pilot study aimed to determine the feasibility and safety of deploying dumbbell-type FCSEMS in patients with CP complicated by MPD stricture.

METHOD

Stents were deployed in 22 patients with MPD stricture caused by CP and complicated by abdominal pain.

RESULTS

Strictures were located at the head (n = 19), body (n = 2), and head and tail (n = 1) of the MPD. Stents were deployed above the papilla in three patients. All stents were deployed for a median duration of 142 (range, 49-190) days and removed. The resolution of MPD strictures was confirmed by pancreatography in 19 (86.3%) patients. Two metal stents that spontaneously tore during removal from two patients had otherwise functioned normally. Only three patients developed recurrent MPD stricture during a median follow-up of 419 (range, 261-484) days..

CONCLUSIONS

Deployment of a dumbbell-type FCSEMS seems feasible for MPD stricture, and the rate of adverse events is acceptable.

Fully covered self-expandable metal stents to dilate persistent pancreatic strictures in chronic pancreatitis: long-term follow-up from a prospective study

BACKGROUND AND AIMS

Symptomatic main pancreatic duct (MPD) strictures secondary to chronic pancreatitis (CP) may benefit from endoscopic insertion of single or multiple plastic stents. MPD stricture resolution after single plastic stent removal is uncommon. The use of removable fully covered, self-expandable metal stents (FC-SEMSs) to dilate MPD strictures secondary to CP was evaluated.

METHODS

Patients with CP and symptomatic MPD stricture located in the head of the pancreas persisting for 3 months or more after placement of a single plastic stent were enrolled in a prospective single-arm trial. A nitinol FC-SEMS was inserted and removed after 6 months. The FC-SEMS diameter and length were chosen according to the stricture anatomy and MPD diameter above the stricture. Our primary objective was FC-SEMS removability. Secondary outcomes were MPD stricture resolution rate and adverse events.

RESULTS

Between December 2012 and October 2014, 15 patients (10 male, mean age 60 years) were enrolled. Pancreatic calcifications were present in 6 (40%) patients. Four patients (27%) had a history of alcohol abuse. In 10 patients, the FC-SEMS was inserted through the major papilla, whereas 5 patients (3 pancreas divisum, 2 dominant dorsal duct) received the stent through the minor papilla. One patient developed cholangitis after 24 hours due to occlusion of the biliary sphincterotomy from the FC-SEMS; cholangitis resolved after insertion of a plastic biliary stent. Complete distal migration of the FC-SEMS was reported in 7 patients (47%) (5 asymptomatic, 2 symptomatic with recurrence of pancreatitis). All migrations occurred with the 3-cm-long FC-SEMS. Four patients (27%) developed de novo stricture induced by the FC-SEMS at the level of the flared end and were excluded from the follow-up; 1 patient with FC-SEMS migration had failed stricture resolution. One patient was lost to follow-up. Finally, 9 patients with MPD stricture resolution had a mean follow-up of 38.9 months (range, 5.3-55.3 months), and 89% were asymptomatic.

CONCLUSIONS

FC-SEMS removability from the MPD in CP was feasible in all cases, and 90% of the patients were asymptomatic after 3 years. Migration seems more frequent with the 3-cm-long FC-SEMS. Occurrence of FC-SEMS-induced pancreatic strictures is a major issue and deserves further assessment. According to our experience, pancreatic FC-SEMSs have promising results, but a careful evaluation in the setting of clinical trials is needed.

Long-term outcomes of 6-mm diameter fully covered self-expandable metal stents in benign refractory pancreatic ductal stricture

BACKGROUND AND AIM

Fully covered self-expandable metal stent (FCSEMS) placement has been tried for pancreatic ductal strictures in chronic pancreatitis. However, the long-term outcome of this procedure remains unknown. The present study aimed to investigate the procedural and long-term outcomes of FCSEMS placement in patients with benign refractory pancreatic ductal strictures.

METHODS

Between August 2011 and September 2015, 18 patients underwent endoscopic treatment with FCSEMS for benign refractory pancreatic ductal stricture. Technical success, clinical success, radiological success, and adverse events were assessed.

RESULTS

Stent placement was successful in all patients (technical success rate, 100%). Reduction in pain score of >50% was achieved in 15 of the 18 patients (clinical success rate, 83.3%). In all patients, stents could easily be removed at a median of 7.5 months (interquartile range [IQR], 6-13.6) after their insertion. FCSEMS migration did not develop in any patient. Ductal stricture was improved in 15 patients (radiological success rate, 83.3%). After definite stent removal, 13 of the 15 (86.7%) patients who had responded to pancreatic stenting maintained the response during follow up (median of 47.3 months; IQR, 7.4-57.1).

CONCLUSIONS

FCSEMS placement appears to be safe and effective for the treatment of benign refractory pancreatic ductal strictures as it can provide persistent improvement in the stricture in long-term follow up.

Management of Benign and Malignant Pancreatic Duct Strictures

The diagnosis and management of pancreatic strictures, whether malignant or benign, remain challenging. The last 2 decades have seen dramatic progress in terms of both advanced imaging and endoscopic therapy. While plastic stents remain the cornerstone of the treatment of benign strictures, the advent of fully covered metal stents has initiated a new wave of interest in calibrating the pancreatic duct with fewer sessions. In malignant disease, palliation remains the priority and further data are necessary before offering systematic pancreatic stenting.

Placement of a 6 mm, fully covered metal stent for main pancreatic head duct stricture due to chronic pancreatitis: a pilot study (with video)

BACKGROUND

Temporary stent placement is widely performed for pancreatic duct stenosis due to chronic pancreatitis. A fully covered self-expandable metal stent (FCSEMS) has a larger diameter, and therefore longer stent patency, and the effect of expansion of the main pancreatic duct stricture may be obtained. However, if stent migration upstream occurs, stent removal is extremely difficult. In addition, because of the diameter gap between the FCSEMS and the main pancreatic duct, stent-induced ductal change may occur. To prevent these adverse events, the technical feasibility, safety and efficacy of the placement of a novel 6 mm diameter FCSEMS with a long suture, to facilitate its removal in cases of stent migration upstream, were evaluated in a pilot study.

METHODS

Between December 2014 and August 2015, symptomatic chronic pancreatitis patients with abdominal pain and a main pancreatic head duct stricture were enrolled. Stent placement for main pancreatic duct stricture was performed under endoscopic retrograde cholangiopancreatography (ERCP) guidance and stent removal was performed within 6 months.

RESULTS

A total of 13 patients were retrospectively enrolled in this study. Metal stent insertion was successfully performed in all patients and clinical success was high (12/13, 92%). As adverse events, stent migration upstream was seen in two patients. Another 11 patients successfully underwent stent removal without any adverse events. During follow up (median 258 days), 2 patients still underwent pancreatic duct stenting because of continuing main pancreatic duct stricture.

CONCLUSION

In conclusion, this novel FCSEMS is acceptable for stent placement in cases of chronic pancreatitis with a main pancreatic duct stricture.

Role of endoscopic retrograde cholangiopancreatography in the management of benign biliary strictures: What’s new?

Benign biliary strictures comprise a heterogeneous group of diseases. The most common strictures amenable to endoscopic treatment are post-cholecystectomy, post-liver transplantation, related to primary sclerosing cholangitis and to chronic pancreatitis. Endoscopic treatment of benign biliary strictures is widely used as first line therapy, since it is effective, safe, noninvasive and repeatable. Endoscopic techniques currently used are dilation, multiple plastic stents insertion and fully covered self-expandable metal stents. The main indication for dilation alone is primary sclerosing cholangitis related strictures. In the vast majority of the remaining cases, temporary placement of multiple plastic stents with/without dilation is considered the treatment of choice. Although this approach is effective, it requires multiple endoscopic sessions due to the short duration of stent patency. Fully covered self-expandable metal stents appear as a good alternative to plastic stents, since they have an increased radial diameter, longer stent patency, easier insertion technique and similar efficacy. Recent advances in endoscopic technique and various devices have allowed successful treatment in most cases. The development of novel endoscopic techniques and devices is still ongoing.

Feasibility and safety of a fully covered self-expandable metal stent with antimigration properties for EUS-guided pancreatic duct drainage: early and midterm outcomes (with video)

BACKGROUND AND AIMS

Recently, EUS-guided pancreatic duct drainage (EUS-PD) has been used for patients in whom endoscopic retrograde pancreatography (ERP) has failed. Stent-related adverse events such as stent migrations, failures in stent placement, or pancreatic fluid leakages have been of concern in transmural plastic stenting procedures. The aim of this study is to evaluate the feasibility and safety of EUS-PD with a fully covered self-expandable metal stent (FCSEMS) for patients with obstructive pancreatitis who failed ERP.

METHODS

Twenty-five consecutive patients with painful obstructive pancreatitis underwent EUS-PD with a FCSEMS after failed ERP. Technical and clinical success, adverse events, and stent patency were assessed.

RESULTS

EUS-PD was successful in all 25 patients (technical success rate, 100%), and symptoms improved in all patients (clinical success rate, 100%). EUS-guided pancreaticogastrostomy (n = 23), pancreaticoduodenostomy (n = 1), and pancreaticojejunostomy (n = 1) were performed. Pain scores improved significantly after FCSEMS placement (P = .001). Early mild grade adverse events occurred in 5 patients (20%), 4 with self-limited abdominal pain and 1 with minor bleeding. No other adverse events related to FCSEMS, including stent migration, stent clogging, pancreatic sepsis, and stent-induced ductal stricture, were observed during follow-up periods. Mean stent patency duration was 126.9 days during mean follow-up periods (221.1 days).

CONCLUSIONS

EUS-PD with an FCSEMS may be technically feasible and relatively safe for patients who fail conventional ERP. Further randomized trials comparing EUS-PD with long-term FCSEMS and plastic stents for patients with painful obstructive pancreatitis after failed ERCP should be encouraged.

Endoscopic drainage of pancreatic fluid collections using a fully covered expandable metal stent with antimigratory fins

BACKGROUND AND OBJECTIVES

Endoscopic drainage is the first consideration in treating pancreatic fluid collections (PFCs). Recent data suggests it may be useful in complicated PFCs as well. Most of the available data assess the use of plastic stents, but scarce data exists on metal stent management of PFCs. The aim of our study to evaluate the efficacy and safety of a metal stent in the management of PFCs.

PATIENTS AND METHODS

Data were collected prospectively on 47 patients diagnosed with PFCs from March 2007 to August 2011 at 3 tertiary care centers. These patients underwent endoscopic transmural placement of a fully covered self-expanding metal stent (FCSEMS) with antimigratory fins of 10 mm diameter.

RESULTS

The stent was successfully placed in all patients, and left in place an average of 13 weeks (range 0.4-36 weeks). Etiology of the PFC was biliary pancreatitis (23), pancreas divisum (2), trauma (4), hyperlipidemia (3), alcoholic (8), smoking (2), idiopathic (4), and medication-induced (1). PFCs resolved in 36 patients, for an overall success rate of 77%. Complications included fever (3), stent migration (2) and abdominal pain (1).

CONCLUSIONS

The use of FCSEMS is successful in the majority of patients with low complication rates. A large sample-sized RCT is needed to confirm if the resolution of PFCs is long-standing.

Outcome of stenting in biliary and pancreatic benign and malignant diseases: A comprehensive review

Endoscopic stenting has become a widely method for the management of various malignant and benign pancreatico-biliary disorders. Biliary and pancreatic stents are devices made of plastic or metal used primarily to establish patency of an obstructed bile or pancreatic duct and may also be used to treat biliary or pancreatic leaks, pancreatic fluid collections and to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis. In this review, relevant literature search and expert opinions have been used to evaluate the outcome of stenting in biliary and pancreatic benign and malignant diseases.

A Duodenal Ulcer Caused by Pancreatic Ductal Hypertension with Chronic Pancreatitis

We herein describe the case of a 67-year-old woman with a duodenal ulcer thought to be caused by elevated pancreatic ductal pressure. The patient complained of continuous upper abdominal pain. Her medical history included idiopathic chronic pancreatitis. Endoscopy revealed a huge duodenal ulcer located on the inferior duodenal angle, which had not been seen on endoscopic retrograde pancreatography two months previously. A combination study using endoscopy and contrast imaging confirmed the relationship between the duodenal ulcer and the pancreatic branch duct. To our knowledge, this is the first case of duodenal ulcer thought to be caused by elevated pancreatic ductal pressure.

Endoscopic therapy in chronic pancreatitis: current perspectives

Endoscopic therapy in chronic pancreatitis (CP) aims to provide pain relief and to treat local complications, by using the decompression of the pancreatic duct and the drainage of pseudocysts and biliary strictures, respectively. This is the reason for using it as first-line therapy for painful uncomplicated CP. The clinical response has to be evaluated at 6-8 weeks, when surgery may be chosen. This article reviews the main possibilities of endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) therapies. Endotherapy for pancreatic ductal stones uses ultrasound wave lithotripsy and sometimes additional stone extractions. The treatment of pancreatic duct strictures consists of a single large stenting for 1 year. If the stricture persists, simultaneous multiple stents are applied. In case of unsuccessful ERCP, the EUS-guided drainage of the main pancreatic duct (MPD) or a rendezvous technique can solve the ductal strictures. EUS-guided celiac plexus block has limited efficiency in CP. The drainage of symptomatic or complicated pancreatic pseudocysts can be performed transpapillarily or transgastrically/transduodenally, preferably by EUS guidance. When the biliary stricture is symptomatic or progressive, multiple plastic stents are indicated. In conclusion, as in many fields of symptomatic treatment, endoscopy remains the first choice, either by using ERCP or EUS-guided procedures, after consideration of a multidisciplinary team with endoscopists, surgeons, and radiologists. However, what is crucial is establishing the right timing for surgery.

Temporary placement of a fully covered self-expandable metal stent in the pancreatic duct for aiding extraction of large pancreatic duct stones: preliminary data

BACKGROUND AND AIM OF STUDY

Endoscopic clearance of large stones in the pancreatic duct (PD) is very difficult, even in patients undergoing stone fragmentation by extracorporeal shock wave lithotripsy. Placement of fully covered self-expandable metal stents (FCSEMSs) has not yet been reported to aid extraction of large PD stones. This aim of this study is to evaluate the technical success and safety of temporary placement of a FCSEMS in the PD to aid extraction of large PD stones.

PATIENTS AND METHODS

Here, we report a pilot study and retrospective case series. Eight patients with chronic pancreatitis and large stones in the PD received endoscopic treatment. Eight symptomatic patients with more than three PD stones of large diameter (≥10 mm) were selected for FCSEMS placement and participation in this study. The patients' PD stones were located in the head, neck, and/or body of the pancreas and could not be cleared using a balloon catheter and basket. After placement of a FCSEMS (10 mm diameter) in the PD between 1 and 5 months (mean duration: 71 days), standard endoscopic maneuvers led to clearance of large PD stones. Technical success was defined as successful stent placement and the ability to achieve PD clearance in two endoscopic sessions. Complications were assessed according to consensus criteria.

RESULTS

FCSEMSs were placed successfully in all patients and PD stones were all cleared easily from the dilated PD using the retrieval balloon and basket. There were no significant complications such as acute pancreatitis, hemorrhage, migration, or stent incarceration. At the 6-month follow-up, no residual stones were observed on pancreatography, and all patients were doing well, without any symptom recurrence.

CONCLUSION

Temporary placement of an FSCEMS in the PD is a minimally invasive and feasible approach for aiding extraction of large PD stones.

Covered metal stent or multiple plastic stents for refractory pancreatic ductal strictures in chronic pancreatitis: a systematic review

BACKGROUND AND AIMS

Refractory chronic pancreatitis has been proposed as a challenge for endoscopists following routine single plastic stenting. However, data on the efficacy and safety of further endoscopic stenting are still controversial. The current systematic review aimed to assess the efficacy and safety of placement of fully covered self-expandable metal stent (FCSEMS) and multiple plastic stents.

METHODS

Databases including MEDLINE, EMBASE, the Cochrane Library, CBM, CNKI, VIP, and WANFANG Database were used to search relevant trials. Published studies were assessed by using well-defined inclusion and exclusion criteria. The process was independently performed by two investigators.

RESULTS

A total of 5 studies provided data of 80 patients. Forest plots and publication bias were not carried out because few studies were relevant and screened studies were all case series. The technical success rate was 100% both in placement of FCSEMS and multiple plastic stents. The functional success rate after placement of FCSEMS was 100%, followed by multiple plastic stents (94.7%). Complications occurred 26.2% after FCSEMS placement, which was not described in detail in multiple plastic stents. The stent migration rate was 8.2% for FCSEMS and 10.5% for multiple plastic stents. Reintervention rate was 9.8% for FCSEMS and 15.8% for multiple plastic stents. Pain improvement rate was 85.2% for FCSEMS and 84.2% for multiple plastic stents.

CONCLUSIONS

FCSEMS appeared to be no significant difference with multiple plastic stents in treatment of refractory chronic pancreatitis. We need to develop more investigations.

Endoscopic therapy for chronic pancreatitis

Endoscopic therapy is recommended as the first-line therapy for painful chronic pancreatitis with an obstacle on the main pancreatic duct (MPD). The clinical response should be evaluated at 6 to 8 weeks. Calcified stones that obstruct the MPD are first treated by extracorporeal shockwave lithotripsy; dominant MPD strictures are optimally treated with a single, large, plastic stent that should be exchanged within 1 year even in asymptomatic patients. Pancreatic pseudocysts for which therapy is indicated and are within endoscopic reach should be treated by endoscopy.

Palliation of pancreatic ductal obstruction in pancreatic cancer

Pancreatic stenting for patients with obstructive pain secondary to a malignant pancreatic duct stricture is safe and effective, and should be considered a therapeutic option. Although pancreatic stenting does not seem to be effective for patients with chronic pain, it may be beneficial in those with obstructive type pains, pancreatic duct disruption, or smoldering pancreatitis. Fully covered metal stents may be an option, but data on their use are limited. Further studies, including prospective randomized studies comparing plastic and metal stents in these indications, are needed to further validate and confirm these results.

Reintervention for occluded biliary metal stent for patients with malignant distal biliary stricture

A metal stent has a longer stent patency than a plastic stent in patients with unresectable malignant distal biliary stricture. However, treatment for stent dysfunction of a metal stent remains unresolved. A review of reported articles regarding reintervention for metal stent dysfunction showed that causes of stent dysfunction included tumor ingrowth/overgrowth, stone/sludge/food impaction, and stent migration. Cleaning of the stent is associated with an early relapse of stent dysfunction. Additional placement of a covered metal stent is expected to have a longer stent patency than that of other stents such as uncovered metal stents or plastic stents. It is recommended that occluded covered metal stents be removed if possible. Stent trimming with argon plasma coagulation is sometimes useful for the treatment of stent displacement. No strategy for occluded metal stents has been established yet. Further clinical trials regarding proper treatments are necessary.

Therapeutic endoscopic retrograde cholangiopancreatography and instrumentation

Over the last 40 years, endoscopic retrograde cholangiopancreatography (ERCP) has evolved from being a purely diagnostic to a primarily therapeutic procedure. The 2 recent developments in ERCP-based stricture management include the increased use of cholangioscopy-guided sampling and self-expandable metal stents. The role of ERCP in pancreatic diseases continues to evolve; ERCP-based pancreatic therapy requires advanced endoscopic expertise and is associated with a high rate of postprocedure complications. Therefore, a multidisciplinary team approach at a center with expertise in pancreatic therapy should serve as a basis for very careful patient selection.

Endoscopic retrograde cholangiopancreatography for stone burden in the bile and pancreatic ducts

Stones in biliary and pancreatic ducts are entities that plague hundreds of thousands of patients worldwide every year. Symptoms can be mild (pain) to life threatening (cholangitis, severe acute pancreatitis). In the last few decades, management of these stones has transitioned from exclusively surgical to now predominantly endoscopic techniques. This article reviews the evolution of endoscopic techniques used in the management of stones in the common bile duct and pancreatic duct.

Endoscopic treatment for biliary stricture secondary to chronic pancreatitis

The causes of benign biliary stricture include chronic pancreatitis, primary/immunoglobulin G4-related sclerosing cholangitis and complications of surgical procedures. Biliary stricture due to fibrosis as a result of inflammation is sometimes encountered in patients with chronic pancreatitis. Frey's procedure, which can provide pancreatic duct drainage with decompression of biliary stricture, can be an initial treatment for chronic pancreatitis with pancreatic and bile duct strictures with upstream dilation. When patients are high-risk surgical candidates or hesitate to undergo surgery, endoscopic treatment appears to be a potential second-line therapy. Placement of multiple plastic stents is currently considered to be the best choice as endoscopic treatment for biliary stricture due to chronic pancreatitis. Temporary placement with a fully covered metal stent has become an attractive option due to the lesser number of endoscopic retrograde cholangiopancreatography (ERCP) sessions and its large diameter. Further clinical trials comparing multiple placement of plastic stents with placement of a covered metal stent for biliary stricture secondary to chronic pancreatitis are awaited.

The role of endoscopic retrograde cholangiopancreatography in patients with pancreatic disease

Given the significant risk of pancreatitis and the advent of high-fidelity diagnostic techniques, ERCP is now reserved as a therapeutic procedure for those with pancreatic disease. Early ERCP benefits those with gallstone pancreatitis who present with or develop cholangitis or biliary obstruction. Among those with idiopathic pancreatitis, ERCP may be used to confirm and treat SOD, microlithiasis, and structural anomalies, including pancreas divisum. Pancreatic endotherapy is a consideration to decrease pain in those with pancreatic duct obstruction, although surgical decompression may be more durable, particularly in those with severe disease. Pancreatic duct leaks may respond to endoscopic drainage, but optimal therapy is achieved if a bridging stent can be placed. Finally, using a wire-guided technique and pancreatic duct stents in high-risk patients, particularly in cases of suspected SOD, may minimize the risk of post-ERCP pancreatitis.

Stent selection for both biliary and pancreatic strictures caused by chronic pancreatitis: multiple plastic stents or metallic stents?

Endoscopic stenting is an effective treatment option in the management of both benign biliary strictures and pancreatic ductal strictures. Plastic stents and self-expandable metal stents have been used with variable success for the management of both benign biliary strictures and pancreatic ductal strictures caused by chronic pancreatitis. Fully covered self-expandable metal stents of improved design represent a major technological advance which has added to the endoscopic armamentarium. Both multiple plastic stents and covered self-expandable metal stents have shown promising results. However, data to support the use of self-expandable metal stents over multiple plastic stents or vice versa are still lacking.

Endoscopic therapy in chronic pancreatitis

Chronic pancreatitis (CP) is a debilitating disease that can result in chronic abdominal pain, malnutrition, and other related complications. The main aims of treatment are to control symptoms, prevent disease progression, and correct any complications. A multidisciplinary approach involving medical, endoscopic, and surgical therapy is important. Endoscopic therapy plays a specific role in carefully selected patients as primary interventional therapy when medical measures fail or in patients who are not suitable for surgery. Endoscopic therapy is also used as a bridge to surgery or as a means to assess the potential response to pancreatic surgery. This review addresses the role of endoscopic therapy in relief of obstruction of the pancreatic duct (PD) and bile du ct, closure of PD leaks, and drainage of pseudocysts in CP. The role of endoscopic ultrasound-guided celiac plexus block for pain in chronic pancreatitis is also discussed.

Anchoring flap versus flared end, fully covered self-expandable metal stents to prevent migration in patients with benign biliary strictures: a multicenter, prospective, comparative pilot study (with videos)

BACKGROUND

Recently, placement of fully covered self-expandable metal stents (FCSEMSs) has been proposed as an alternative treatment for the management of benign biliary strictures. However, the major limitations of FCSEMSs are frequent migration and removal complications.

OBJECTIVE

We conducted this study to compare the antimigration effects, complication rates, and short-term efficacy of 2 FCSEMSs with either an anchoring flap (AF) or a flared end (FE) at the proximal end of the stent.

DESIGN

A multicenter, prospective comparative pilot study.

SETTING

Two tertiary referral centers.

PATIENTS

A total of 43 patients with benign biliary stricture who were candidates for placement of FCSEMSs were assigned to the AF (n = 22) or the FE group (n = 21).

INTERVENTIONS

Predefined duration of placement and removal of FCSEMSs.

RESULTS

After a median period of placement of 6 months (interquartile range 4-6), no patients in the AF group and 33% of patients (7 of 21, 1 in proximal and 6 in distal) in the FE group had stent migration (P = .004). The removal rate of the FCSEMSs was 100% in both groups (per protocol, n = 22 in the AF group and n = 17 in the FE group). Immediate improvement of biliary stricture was 91% (20/22, per protocol) in the AF group and 88% (15/17, per protocol) in the FE group. All stents were removed without difficulty.

LIMITATIONS

Short-term follow-up after the removal of FCSEMSs.

CONCLUSIONS

With regard to the antimigration effect of FCSEMSs for benign biliary stricture, the AF design may be superior to the FE. For up to 6 months, both FCSEMSs can be endoscopically removed without complications. (

CLINICAL TRIAL REGISTRATION NUMBER

NCT00945516.).

Placement of a fully covered self-expandable metal stent in a young patient with chronic pancreatitis

Plastic stent insertion is a treatment option for pancreatic duct stricture with chronic pancreatitis. However, recurrent stricture is a limitation after removing the plastic stent. Self-expandable metal stents have long diameters and patency. A metal stent has become an established management option for pancreatic duct stricture caused by malignancy but its use in benign stricture is still controversial. We introduce a young patient who had chronic pancreatitis and underwent several plastic stent insertions due to recurrent pancreatic duct stricture. His symptoms improved after using a fully covered self-expandable metal covered stent and there was no recurrence found at follow-up at the outpatient department.

Modified fully covered self-expandable metal stents with antimigration features for benign pancreatic-duct strictures in advanced chronic pancreatitis, with a focus on the safety profile and reducing migration

BACKGROUND

Fully covered self-expandable metal stent (FCSEMS) placement has recently been tried in the management of refractory pancreatic-duct strictures associated with advanced chronic pancreatitis. The major limitation of FCSEMSs was frequent migration.

OBJECTIVE

To assess the safety, migration rate, and removability of modified FCSEMSs with antimigration features used for the treatment of benign pancreatic-duct strictures.

DESIGN

Prospective study.

SETTING

Tertiary academic center.

PATIENTS

Thirty-two patients with chronic painful pancreatitis and dominant ductal stricture.

INTERVENTIONS

Transpapillary endoscopic placement of FCSEMSs in the pancreatic duct with removal after 3 months.

MAIN OUTCOME MEASUREMENTS

Technical and functional success and adverse events associated with the placement of metal stents.

RESULTS

FCSEMSs were successfully placed in all patients through the major (n = 27) or minor (n = 5) duodenal papilla. All patients achieved pain relief from stent placement. There was no occurrence of stent-induced pancreatitis or pancreatic sepsis. No stent migrated, and all stents were easily removed. Follow-up ERCP 3 months after stent placement showed resolution of duct strictures in all patients. Pancreatograms obtained at FCSEMS removal displayed de novo focal pancreatic duct strictures in 5 patients, but all were asymptomatic.

LIMITATIONS

No long-term follow-up.

CONCLUSIONS

Temporary 3-month placement of FCSEMSs was effective in resolving pancreatic-duct strictures in chronic pancreatitis, with an acceptable morbidity profile. Modified FCSEMSs can prevent stent migration, but may be associated with de novo duct strictures. Further trials are needed to assess long-term safety and efficacy.

Endoscopic treatment in chronic pancreatitis, timing, duration and type of intervention

Endoscopic treatment of chronic pancreatitis (CP) aims to relieve pain by draining the main pancreatic duct (MPD) and to treat loco-regional complications. Half of patients have complete pain relief five years after treatment, with best results obtained if treatment is performed early after the first pain attack. If MPD obstruction is caused by calcifications, ambulatory extracorporeal shock wave lithotripsy has become a first-line treatment (9-30% of patients require ERCP during follow-up). If MPD obstruction is caused by stricture(s), insertion of single plastic stent is effective but it requires multiple ERCPs for stent exchanges; other protocols are being investigated. Pseudocysts represent an excellent indication for endoscopic treatment with long-term results similar to those of surgery; endosonography-guided techniques allow treatment of almost any pancreatic pseudocyst. Biliary strictures related to CP are challenging due to a high relapse rate and requirement for multiple ERCP sessions. Significant progress has recently been made with new protocols of temporary biliary stenting (multiple simultaneous plastic stents or covered metallic stents).

EUS-guided biliary drainage with one-step placement of a fully covered metal stent for malignant biliary obstruction: a prospective feasibility study

OBJECTIVES

Endoscopic ultrasound (EUS)-guided biliary drainage (EUSBD) with plastic stents has been introduced as an alternative to percutaneous transhepatic biliary drainage (PTBD) in cases of biliary obstruction when endoscopic retrograde cholangiopancreatography (ERCP) is unsuccessful. Although self-expandable metallic stents with a larger diameter might offer long-lasting patency compared with plastic stents, to date, EUSBD with one-step placement of a fully covered self-expandable metal stent (FCSEMS) has not been evaluated. We conducted this study to determine the feasibility and usefulness of EUSBD with one-step placement of FCSEMS.

METHODS

A prospective feasibility study on EUSBD with one-step placement of FCSEMS was carried out in 14 patients with malignant biliary obstruction who were candidates for alternative techniques for biliary decompression because of unsuccessful ERCP.

RESULTS

The technical and functional success rate was 100% (14/14). Nine patients were treated using the intrahepatic approach. The remaining five patients were treated using the extrahepatic approach. With the intrahepatic approach, two patients showed self-limited pneumoperitoneum. With the extrahepatic approach, no patients had pneumoperitoneum. No bile peritonitis or cholangitis was observed after the procedure in any of the patients treated using the intra- or extrahepatic approach. During follow-up periods (median 6 months), one case of re-intervention (7%, 1/14) necessitated by distal stent migration was observed.

CONCLUSIONS

EUSBD with one-step placement of an FCSEMS may be feasible, safe, and effective as an alternative to PTBD in cases of malignant biliary obstruction when ERCP is unsuccessful. Prospective randomized trials of EUSBD with plastic stent vs. EUSBD with FCSEMS may be needed.

Covered metallic stents in the management of malignant and benign pancreatobiliary strictures

In the endoscopic management of unresectable malignant biliary obstructions by placement of a metallic stent (MS), longer patency and a lower incidence of stent occlusion are desirable goals. With its mesh structure, the uncovered MS (UMS) is occluded mainly by tumor or tissue ingrowth, making it impossible to remove. The covered MS (CMS) was developed to overcome these disadvantages, and was shown to maintain patency longer than the UMS in our randomized study. The most important characteristic of the CMS is that it is removable, allowing it to be used in patients with resectable malignancies and benign strictures. In addition, the drug-eluting CMS provides an additional approach to the treatment of biliary malignancies. The CMS may also change the treatment paradigm for biliary strictures and strictures due to chronic pancreatitis. The CMS is analogous to a large-bore, expandable plastic stent and is effective both as an endoprosthesis and a dilating or anti-cancer device. However, to better understand the utility of these devices, we need to first consider mechanical properties such as radial force (RF, expansion force) and axial force (AF, straightening force). AF is particularly important when developing CMSs because of related complications.

Management of distal malignant biliary obstruction with the ComVi stent, a new covered metallic stent

BACKGROUND

The covered metallic stent is effective for managing malignant distal biliary obstructions. The most popular covered metallic stent is the covered Wallstent (CWS). This study estimated the efficacy and safety of a new expanded polytetrafluoroethylene (e-PTFE)-covered nitinol metallic stent, the ComVi stent. This covered metallic stent consists of an e-PTFE membrane sandwiched between two uncovered metallic stents with weak axial (straightening) force. Wire is exposed on both the inner and outer surfaces.

METHODS

Between May 2005 and April 2007, ComVi stents were placed consecutively in 47 patients with unresectable malignant distal biliary obstruction. The cases involved 35 pancreatic cancers, 8 metastatic nodes, 2 gallbladder cancers, and 2 bile duct cancers. The patients were compared with 47 patients who received CWS placement between August 2001 and May 2005 matched for age, sex, and causative disease from 133 cases.

RESULTS

No significant differences in stent patency or patient survival were found. Stent occlusion was observed in 13 patients (27.7%) in the ComVi group and 10 patients (21.3%) in the CWS group. The cause of occlusion in both groups was tumor overgrowth (4.25% vs 4.2%), sludge (8.5% vs 6.3%), impaction of food scraps (14.9% vs 2.1%), and bile duct kinking (0% vs 8.4%). Other complications were migration (2.1% vs 17.0%; p = 0.0304) and cholecystitis (2.1% vs 6.3%), and there were significant differences in the incidence of complications except for occlusion (4.2% vs 24.6%; p = 0.0142).

CONCLUSION

The ComVi stent has a patency similar to that of the CWS and a lower incidence of migration. However, early occlusion by food impaction was increased and should be resolved.